Chapter 31 Prep-U

A nurse understands that which sleep pattern is considered normal for a preschooler?

11-13 hours a day

The parent of a 2 year old is concerned her child is talking but she cannot understand her. The nurse explains that this should occur by what age?

3

During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child?

5 years Denver is used from 1 month to 6 years old

A mother visits the clinic for a routine visit with her 5-year-old son. The mother asks the nurse when the child's permanent teeth will erupt. The nurse should explain to the mother that permanent teeth usually begin to erupt by age

6 years

After the age of 2 years, how much do toddlers grow per year?

About 5 cm

A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam?

Allow the child to place the hand under the examiner's hand

The nurse should intervene when observing which parental action as a child is placed in a motor vehicle leaving the hospital?

An infant is placed in a forward facing carseat

A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action?

Apply oxygen via nasal cannula (Children in physiological distress compensate with increased respiratory and heart rates. Physiological distress usually results from a respiratory disorder or significant blood loss. (Even children with a known congenital heart problem rarely present in acute distress from ischemic heart disease.) The additional work of breathing is evidenced in a distressed child by nasal flaring accompanied by supracostal, intercoastal, and subcostal chest retractions (Fig. 27.2) or abdominal breathing. <insert Fig. 27.2> Administration of oxygen and support of the child's ability to breathe are the first interventions. Physiological distress is priority to address, then reassurance and efforts to calm the child can be attempted. Oxygen should be applied before a chest x-ray is obtained. Oxygen can be worn during the x-ray. Prolonged expiration is not the priority treatment during acute distress until oxygen is applied and a complete assessment is performed.)

A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response?

Call the Poison Help Line #1-800-222-1222 for instructions on treatment.

A 12 year old adolescent female presents to the clinic alone requesting birth control and testing and treatment suspected chlamydia. What is the nurse's priority action?

Check state regulations about testing and treatment of minors.

The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate?

Denver Developmental Screening

While attempting to auscultate heart sounds a 2-year old client pushes the nurse's hand away. What should be done to facilitate this assessment?

Give the child something to hold in each hand

While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of

Iron

The nurse is collecting a history on a 4-year-old and discovers that the child is being cared for by his grandmother during the days while the parents are at work. The grandmother's house was built in the early 1940s. Which lab should the nurse prepare to collect from the child?

Lead level

A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect?

Mastitis

The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child?

On the parent's lap

While assessing the head and neck of an 11 year old child, the nurse palpates several tender and swollen lymph nodes. What is the nurse's best action?

Prepare to collect a white blood cell count specimen

A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention?

Raise head of bed and apply oxygen

When assessing the vital signs of a toddler, a nurse records normal temperature, pulse, and respiration, but an elevated blood pressure. What is the initial responsibility of the nurse?

Recheck size of cuff

After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be

Stage 2

Your patient is a 15-year-old male. His testes and scrotum are enlarged and the scrotal skin is darkened. His pubic hair is coarse and curly but does not extend to the thighs. What Tanner stage would you assign to this patient?

Stage 4

The nurse is conducting a health history with an adolescent patient. What should the nurse explain to the patient about confidentiality?

The only thing that I must share is information that concerns your safety."

A woman who speaks primarily Spanish at home brings her 3-year-old to the clinic for a yearly visit. The mother reports concern that her child's language skills are not progressing as expected. The health care provider may have a difficult time assessing this child's language capabilities if

The provider is not bilingual

The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding?

This is a normal finding

The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination?

Unstable gait

What is an appropriate action by a nurse when asking a child about the presence of pain?

Use a pain scale appropriate for the child's developmental level

The nurse determines the heart rate of 100 beats per minute for a 5-year-old patient as being:

WNL

A nurse recognizes that a most valuable communication tool when working with small children is what technique?

actively engage in play

The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to

hop on one foot

The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse?

perianal lacerations extending to external sphincter

While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is

play

The nurse is examining a 3-year-old girl who becomes distressed during the examination. What should you tell the parents?

this behavior is developmentally appropriate